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ID

3155

Description

AMC-070 Missed Visit Form (F35) Lenalidomide in Treating Patients With AIDS-Related Kaposi Sarcoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A121-E89F-E040-BB89AD433766

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=91E448E8-A121-E89F-E040-BB89AD433766

Mots-clés

Versions (1)
  1. 19/09/2012 19/09/2012 -
Téléchargé le

19 septembre 2012

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
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    Nonneoplastic Condition NCT01057121 Follow-Up - AMC-070 Missed Visit Form (F35) - 3147075v1.0

    Anglais

    No Instruction available.

    1 Formulaires  
    1. StudyEvent: AMC-070 Missed Visit Form (F35)
      1. No Instruction available.
    Unnamed1
    Description

    Unnamed1

    Visit number
    Description

    HospitalAdmissionOrdinalNumber

    Type de données

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16696
    UMLS 2011AA ObjectClass
    C0019994
    NCI Thesaurus Property
    C25385
    UMLS 2011AA Property
    C0809949
    Unnamed2
    Description

    Unnamed2

    Missed Visit Date (mm/dd/yyyy)
    Description

    PatientAbsentVisitDate

    Type de données

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property
    C25716
    UMLS 2011AA Property
    C0545082
    Reason patient missed visit
    Description

    PatientAbsentVisitReason

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property
    C25716
    UMLS 2011AA Property
    C0545082
    Other, specify
    Description

    PatientAbsentVisitSpecify

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C48190
    UMLS 2011AA Property
    C0332197
    NCI Thesaurus Property
    C25716
    UMLS 2011AA Property
    C0545082
    Next visit scheduled (Items missed will be made up at the new visit.)
    Description

    PatientScheduleNextVisitInd-2

    Type de données

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C53286
    UMLS 2011AA Property
    C0332282
    NCI Thesaurus Property
    C25211
    UMLS 2011AA Property
    C0086960
    NCI Thesaurus Property
    C25716
    UMLS 2011AA Property
    C0545082
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Comments
    Description

    Comments

    Comments
    Description

    ResearchCommentsText

    Type de données

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Retour au début de la page

    Similar models

    No Instruction available.

    1 Formulaires
    1. StudyEvent: AMC-070 Missed Visit Form (F35)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Type de données
    Alias
    Item Group
    Unnamed1
    HospitalAdmissionOrdinalNumber
    Item
    Visit number
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16696 (NCI Thesaurus ObjectClass)
    C0019994 (UMLS 2011AA ObjectClass)
    C25385 (NCI Thesaurus Property)
    C0809949 (UMLS 2011AA Property)
    Item Group
    Unnamed2
    PatientAbsentVisitDate
    Item
    Missed Visit Date (mm/dd/yyyy)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property)
    C0545082 (UMLS 2011AA Property)
    Item
    Reason patient missed visit
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property)
    C0545082 (UMLS 2011AA Property)
    CL.1
    Code List
    Reason patient missed visit
    CL Item
    Patient Forgot (Patient forgot)
    CL Item
    Health Reasons (Health reasons)
    CL Item
    Patient Could Not Get Off Work (Patient could not get off work)
    CL Item
    Patient Unable To Obtain Dependent Care (Patient unable to obtain dependent care)
    CL Item
    Patient Had Transportation Problems (Patient had transportation problems)
    CL Item
    Patient Unhappy With Frequency Of Visits (Patient unhappy with frequency of visits)
    CL Item
    Scheduling Difficulties (Scheduling difficulties)
    CL Item
    Patient Decided To Discontinue Study (Patient decided to discontinue study)
    CL Item
    Patient Experienced An Adverse Event (Patient experienced an Adverse Event)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PatientAbsentVisitSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C48190 (NCI Thesaurus Property)
    C0332197 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property)
    C0545082 (UMLS 2011AA Property)
    Item
    Next visit scheduled (Items missed will be made up at the new visit.)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C53286 (NCI Thesaurus Property)
    C0332282 (UMLS 2011AA Property)
    C25211 (NCI Thesaurus Property)
    C0086960 (UMLS 2011AA Property)
    C25716 (NCI Thesaurus Property)
    C0545082 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.2
    Code List
    Next visit scheduled (Items missed will be made up at the new visit.)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
    Retour au début de la page 

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